A COMPARATIVE STUDY TO FIND THE

EFFECTIVENESS OF PRESSURE BIOFEEDBACK

VERSUS ISOMETRIC EXERCISES OF DEEP

NECK FLEXORS IN REDUCING CHRONIC NECK

PAIN USING NECK DISABILITY INDEX

By

(Reg. No . 27101805)

PADMAVATH COLLEGE OF PHYSIOTHERAPY PERIYANAHALLI

DHARMAPURI

A COMPARATIVE STUDY TO FIND THE

EFFECTIVENESS OF PRESSURE BIOFEEDBACK

VERSUS ISOMETRIC EXERCISES OF DEEP

NECK FLEXORS IN REDUCING CHRONIC NECK

PAIN USING NECK DISABILITY INDEX

By

(Reg. No . 27101805) Under the guidance of

Mr. K. KUMAR , M.P.T. , MIAP.,

Associate Professor,

Padmavathi College of Physiotherapy

Submitted in Partial fulfillment of the requirements for the

Degree of Master of Physiotherapy

From

The Tamilnadu Dr. M.G.R. Medical University,

Chennai

PADMAVATH COLLEGE OF PHYSIOTHERAPY PERIYANAHALLI

DHARMAPURI

CERTIFICATE

This is to certify that the project entitled “A COMPARATIVE

STUDY TO FIND THE EFFECTIVENESS OF PRESSURE

BIOFEEDBACK VERSUS ISOMETRIC EXERCISES OF

DEEP NECK FLEXORS IN REDUCING CHRONIC NECK

PAIN USING NECK DISABILITY INDEX”

Submitted by the candidate

(Reg. No . 27101805) is a bonafide work done in partial fulfillment of the requirements for the

Degree of Master of Physiotherapy from

The Tamilnadu Dr. M.G.R. Medical University,

Chennai

Guide Principal

Viva-voce Examination held on ________________

Internal Examiner External Examiner

DECLARATION

I hereby declare and present my dissertation entitled entitled “A

COMPARATIVE STUDY TO FIND THE EFFECTIVENESS

OF PRESSURE BIOFEEDBACK VERSUS ISOMETRIC

EXERCISES OF DEEP NECK FLEXORS IN REDUCING

CHRONIC NECK PAIN USING NECK DISABILITY

INDEX” the outcome of the original research work undertaken

and carried out be me , under the guidance of Mr. K. KUMAR ,

M.P.T. , MIAP., Associate Professor , Padmavathi College of

Physiotherapy, Periyanahalli, Dharmapuri , Tamilnadu.

I also declare that the material of this dissertation had not

formed in any basis for the award of any other Degree previously

from the Tamilnadu Dr. M.G.R. Medical University, Chennai.

(SITHARTHAN. M )

ACKNOWLEDGEMENT

First and foremost I thank LORD ALMIGHTY for

showering the blessings who always been my source of strength

and guided me in all endeavors leading to the completion of this

project.

My heartful gratitude to the Honorable Chairman

Mr.M.G.SEKAR,B.A.B.L. Padmavathi College of Physiotherapy,

Periyanahalli, for providing me the valuable opportunity for doing

my Bachelor Degree in Physiotherapy.

My sincere and devoted thanks to my project guide

Mr. K. KUMAR, M.P.T. , MIAP., Associate Professor for

Padmavathi College of Physiotherapy , for his inspiration and

guidance throughout this thesis.

I wish to express my sincere thanks to Mr. K.KUMAR,

M.P.T.,M.I.A.P., Principal, Padmavathi College of Physiotherapy,

for his valuable advice , suggestions and encouragements in

making this project a successful one.

My sincere thanks to STAFF MEMBERS of Padmavathi

College of Physiotherapy, for their continuous support in making

this project a successful one.

I express my special thanks to all of my FRIENDS for

sharing their knowledge and support each and every step of this

thesis work.

I take this golden opportunity to thank each and every patient

who took part in this study, for his or her kind cooperation and

needed information

(SITHARTHAN. M )

DEDICATED TO MY BELOVED

PARENTS , STAFFS

AND

LOVABLE FRIENDS

TABLE OF CONTENTS

CHAPTERS Page No

I. INTRODUCTION

1. Introduction 1

II. REVIEW OF LITERATURE

1. Review of Literature 28

III. MATERIALS & METHODOLOGY

1. Research Design 34

IV. RESULTS

1. Research Design 39

V. DISCUSSION

1. Discussion 53

VI. CONCLUSION

1. Conclusion 59

REFERENCES 61

APPENDICES

ANNEXURE - I 68

ANNEXURE - II 73

ANNEXURE - III 76

1

INTRODUCTION

Neck pain is a major problem in the society, with an increasing

sedentary population especially with reliance on computer technology in

the workplace.

Pain is defined as a sensation characterized by a group of

unpleasant perceptual and emotional experiences that triggers autonomic,

psychologic and somatomotor response associated with actual (or)

potential damage to the tissues1. Mechanical neck pain may be defined as

pain secondary to overuse of a normal anatomic structure (or) pain

secondary to injury (or) deformity of an anatomic structure2.

Neck pain is considered to be chronic if it last for more than 3

months of duration and pain that continues after the stimulus is removed

(or) the tissue damage heals. Chronic neck pain is becoming increasingly

prevalent in society estimations indicated that 67% of individuals will

suffer neck pain at some stage throughout life. The current research

incidence of chronic neck pain in Bangalore has been estimated as 35%

and the median age as 27 years and its ranges between 18 to 52 years.

It is estimated that the Osteo -ligamentous system contributes 20%

to the mechanical stability of the cervical spine, while 80% is provided by

2

the surrounding neck musculature. The ligaments role in stabilization

occurs mainly at end of range postures3. While muscles supply dynamic

support in activities around the neutral and mid range postures, which are

commonly adopted during functional daily tasks. In the presence of injury

(or) pathology, the role of the muscular system becomes even greater

which highlights the need to address the muscle system during both the

assessment and rehabilitation of patient with neck pain.

Considerable clinical knowledge and theory exists about the nature

of the muscle dysfunction and postural change in the neck and upper

functional kinetic chain that can occur with painful dysfunction of the

craniocervical and cervical regions as well as of the cranio mandibular

complex. The dysfunction in the muscular system appears to be related to

disproportionate activity levels between different muscle, which may be

provocative (or) reactive to painful musculoskeletal dysfunction. It is

thought that this imbalanced muscle activity may arise from inherently

poor sensorimotor integration (or) may be acquired through the effects on

the muscular system of motor patterns used in life style activities (or)

acquired from the effects of trauma and pain on articular and soft tissues.

This imbalanced activity can result in postural change and poor patterns

of movement in the neck. The articular tissues often fail to receive

sufficient active, protective support from muscular having a prime

3

stabilization role with resulting altered mechanics and an altered load

distribution on articular and soft tissues the cervical tissues are subjected

to adverse stress and chronic strain with resultant pain.

Further more it was demonstrated that these stresses could be

relieved if the supporting muscles principally the upper and deep cervical

flexors were functioning at a level where they could repeatedly hold a

low load inner range contraction without postural function. There is

clinical evidence that the upper and deep cervical flexor that are the

important muscles for cervical segmental and postural control lose their

endurance capacity in patients with neck pain. The increased

understanding of the tonic supporting role of the deep neck flexors and

their functional differentiation from the superficial flexors realizes the

need to develop a test that would target these muscles in relative isolation

from their superficial counterparts.

To test this hypothesis a low load craniocervical flexion test has

been developed by Jull et al to investigate the anatomical action of the

deep cervical flexors, specifically of the longus colli in synergy with the

longus capitis. The craniocervical flexion test (CCFT) is a clinical test

used to assess an individual’s ability to slowly perform and hold a precise

upper cervical flexion action without flexion of mid and lower cervical

4

spine. It is based on the anatomical interrelated action of the deep

muscles to support and stabilize the cervical spine as well as produce a

flattening of the normal cervical spine lordosis4. This test is conduced in

supine lying with the head neck region supported in neutral position. The

action is reasoned to recruit all the deep neck flexors to hold the head and

cervical region in a static position. As the muscles are deep and unable to

be palpated directly, an indirect quantification of their ability to hold the

cervical spine position is gained by monitoring the steady position of he

neck with an inflatable air filled pressure sensor (stabilizer Chattanooga

south pacific) that is positioned sub occipitally behind the neck. Work is

currently proceeding to establish the validity of this test although initial

clinical data suggest that it can depict a deficit in function in patients with

neck pain. This dysfunction improves with retraining and parallels a

reduction in symptoms.

Segmental instability has been defined as occurring in patients with

neck problems whose clinical status is unstable, with symptoms

fluctuating between mild and severe symptoms in response to even minor

provocations. Frymoyer et al defined segmental instability as “a condition

where there is loss of spinal stiffness, such that normally tolerated

external loads will result in pain, deformity, or place neurological

structures at risk”

5

Panjabi introduced an innovative model of the spinal stabilization

system which serves as an appropriate model for understanding the entity

of spinal stability and instability and fits the clinical paradigm for the

assessment and treatment in the neck pain patients.

The model incorporates

Passive subsystem - osseous and articular structures and the spinal

ligaments.

Active subsystem - force generating capacity of the muscles.

Neural control subsystem – control of these muscles.

This model recognizes that muscles need to be programmed in

response to feedback (e.g. from sensory cues from ligaments), in order to

adjust to any condition in any point in time so that the appropriate

muscles are activated to the appropriate level. The three subsystems are

interdependent components of the spinal stabilization system with one

capable of compensating for deficits in another. Neck pain can occur as a

consequence of deficits in control of the spinal segment when abnormally

large segment motions cause compression or stretch on neural structures

or abnormal deformation of the ligaments and pain sensitive structures.

6

It appears the local stability system dysfunction only develops after

the onset of pain and pathology. Patient education may be an important

component in the non surgical treatment of patients with segmental

instability. . Patients also should be made aware of the importance of

maintaining muscle strength and endurance, particularly in the muscles of

the cervical spine. Fatigue can adversely affect the ability of the spinal

muscles to respond to imposed loads, and general strengthening programs

have been shown to be effective in patients with chronic Neck pain5.

Anecdotal evidence suggests that cervical flexor muscles become

dysfunctional in the presence of neck pain, further simple clinical

mechanical measures have demonstrated a reduction in the strength and

endurance capabilities of the deep cervical flexor muscles in neck pain

patients.

SPB plays an important role in enhance motor learning of the

affected muscles by visual feedback and helps in increasing the strength

of the muscles and improves stabilization and relieves pain6. Isometric

exercise helps in improving the muscle tension and strengthens the

muscles there by helps in relieving pain.

7

ANATOMY

FIGURE 1

(Courtesy: Neck surgery.com)

8

The Cervical spine is made up of first seven vertebrae in the spine;

it starts just below the skull and ends at the top of thoracic spine. The

Cervical spine has a backward “C” shape lordotic curve and is much

more mobile than either of thoracic or lumbar regions of the spine. The

Cervical spine has special openings in each vertebra for the arteries that

carry blood to the brain.

The first two vertebral bodies in the cervical spine are called Atlas

and Axis. Atlas is named after a mythical Greek god who supported the

weight of the world on his shoulders because this is the vertebral body

that supports the weight of the head. The Atlas and Axis vertebra in the

cervical spine differ from all other vertebrae because they are designed

primarily for rotation.

The Atlas has a thick anterior arch and thin posterior arch with two

prominent masses. The Axis sits underneath the Atlas and has a bony

knob called the Odontoid Process that articulates up with the Atlas. It is

this mechanism that allows the head to turn side to side.

There are special ligaments between these two vertebrae to allow

for rotation between these two bones. Between each vertebra in the

cervical spine are discs which acts as shock absorbers and also permits

some movement between the vertebral bodies.

9

VERTEBRAE

FIGURE 2

(Courtesy: Seeley textbook of Anatomy and Physiology)

10

The entire Spinal column is joined together by ligaments that allow

the Spine to bend and twist carrying the weight of the human body with

just the right balance of strength and flexibility. Special joints between

each of the vertebral bodies called Facet joints allow the individual bones

of the spine to move and rotate with respect to each other .These joints

are important because they can be source of pain if they become arthritic.

Each vertebra is shaped in a special way so that when they are

stacked together, Spinal cord is protected from damage or injury by the

bones of the entire spinal column. Vertebrae support the majority of the

weight imposed on the spine. The body of each vertebra is attached to a

bony ring that consists of several parts.

A bony projection on either side of the vertebral body called the

Pedicle supports the arch that protects the Spinal canal. The laminae are

the parts of the vertebrae that form the back of the bony arch that

surrounds and covers the spinal canal. There is a transverse process on

either side of the arch where some of the muscles of the Spinal column

attach to the vertebrae. The Spinous process is the bony portion of the

vertebral body that can be felt as a series of prominence in the centre of

the person’s neck and back.

11

INTERVERTEBRAL DISC

It is located in between each vertebrae and functions as a shock

absorber and as joints; they are designed to absorb the stresses carried by

the Spine while allowing the vertebral bodies to move with respect to

each other. They are made up of a strong outer ring of fibers called the

Annulus Fibrosis and a soft centre called the Nucleus Pulposus. The outer

layer Annulus Fibrosis helps to keep the inner layer Nucleus Pulposus

intact. The Annulus is made up of very strong fibers that connect each

vertebra together. The Nucleus of the disc has a very high water content

making it very moist.

FACET JOINT

FIGURE 3

(Courtesy: Neck surgery.com)

12

The Facets connect the bony arches of each of the vertebral bodies.

There are two Facet joints between each pair of vertebrae, one on each

side. Facet joints connect each vertebra with the next vertebrae above and

below. They are primarily designed to allow the vertebral bodies to rotate

with respect to each other.

NEURAL FORAMEN

The Neural foramen is the opening where the nerve roots exit the

spine and travel to the rest of the body. There are two Neural foramen

located between each pair of vertebrae, one on each side. The foramen

creates a protective passage way for the nerves that carry signals between

the Spinal cord and rest of the body.

SPINALCORD AND NERVE ROOTS

The Spinal cord extends from the base of the brain to the area

between bottom of first lumbar vertebrae and top of second lumbar

vertebrae. The Spinal cord ends by dividing into individual nerves that

travel out to lower body and legs. This group of nerves at end of the

Spinal cord called CaudaEquina or Horse Tail. For the short distance

these nerves travel through the Spinal canal before they exit out the

Neural Foramen. The Duramater is the protective membrane that covers

the Spinal cord; the Duramater forms a water tight sac around the Spinal

cord and Nerves.

13

The Spinal cord is surrounded by spinal fluid inside this sac. The

nerves in each area of the Spinal cord connect to specific parts of the

body. The nerves of the cervical spine go to the upper chest and arms, the

nerves also carry electrical signals back to the brain creating sensations.

Damage to the nerves, nerve roots or spinal cord can lead to symptoms

such as pain, tingling, numbness and weakness.

LIGAMENTS OF CERVICAL VERTEBRAL COLUMN

The vertebral bodies are bordered front and back by two major

ligaments. The anterior longitudinal ligament is a broad, strong ligament

on the anterior and antero lateral aspects of the vertebral bodies from the

atlas too the sacrum. The posterior longitudinal ligament lies on the

posterior surface of the bodies of the vertebrae from the axis to the

sacrum. Supraspinous and interspinous ligaments are present between

adjacent Spinous processes. The articulations between the vertebral

arches are maintained by the Supraspinous ligaments, which become

ligament nuchae in cervical spine, the interspinous ligaments, the

ligamentum flavum and the synovial facet joints and capsules.

Supraspinous ligament is thin which is composed of high percentage of

elastic tissue, and runs over the tips of the Spinous processes. In humans

this structure extends from the vertebrae prominence to the external

14

occipital protuberance and it is probably a major stabilizer of head and

neck.

MUSCLES AND FASCIA OF THE CERVICAL SPINE

The muscles of the neck can be defined by anatomic limits,

innervations or function. Because the cervical spine is the most mobile

section of the spine, it contains the most elaborate a specialized muscle

system of the spine. Many muscle groups that move the trunk and limbs

also attach to the spinal column.

The muscles that closely surround the bones of the spine are

important for maintaining posture and help the spine to carry the loads

created during normal activities, work and play. The four pre vertebral

muscles of the neck are the longus colli (cervicis), the longus capitis,

rectus capitus anterior and rectus capitis lateralis. These are weak flexors

of the head and neck. They extend from the base of the skull to superior

mediastinum. They partially cover the anterior aspect of the vertebral

column. They are covered anteriorly by the thick pre vertebral fascia.

These fascia forms planes and compartments in which deeper structures

of the neck are organized.

The three fascial layers of the cervical spine are superficial,

intermediate and deep fascia. The superficial fascia surrounds

15

subcutaneous fat, the platysma muscle, the external jugular vein and

cutaneous sensory nerves. The superficial layer surrounds all the deeper

structures of neck. Next to the anterior to the cervical spine are

oesophagus, trachea and thyroid gland. These structures are covered by

intermediate fascial layer separate from the prevertebral fascia. The

middle layer of the deep cervical fascia encloses the strap muscles and

extends laterally to the scapula. The deepest layer of the deep fascia is the

prevertebral fascia, which covers the scalenus muscles, longus colli

muscles and the anterior longitudinal ligament. A number of important

structures are located between these fascial layers.

BLOODSUPPLY OF THE CERVICAL SPINE

The vertebral artery is the major source of blood supply for the

cervical spine and the cervical portion of the spinal cord. The vertebral

arteries are usually the first and largest branch of the subclavian artery on

each side.

BIOMECHANICS OF CERVICAL SPINE

The normal function of the cervical spine requires both flexibility

to move the head and endurance of the musculature. The neck normally

moves more than 600 times each hour, whether a person is awake (or)

asleep. A basic understanding of the clinically relevant biomechanics of

16

the cervical spine is necessary for making a complete assessment of the

neck of patients who have cervical problems. The normal biomechanics

and pathomechanics of the cervical spine have been learned from static

mechanical testing of cadaveric specimens in the laboratory. It is well

established that forces and stresses can be applied to the spine in any

combination of flexion, extension, rotation and shear. These stresses

affect the entire Motion segment including the intervertebral disc,

zygapophyseal ligaments, un co vertebral joints and the other ligamentous

structures. The muscles and fascial attachments interact with the cervical

spine to accommodate load, alter forces and direct motion.

The cervical spine is better suited for mobility and is not required

to transmit heavy loads. The head weights only 5 to 7 pounds. All vital

nerve centers are in the skull and allow coordination of vision, vestibular

balance and auditory direction, precise control of head position and

movement is essential for normal functioning of those senses. The

biomechanical studies involving the cervical spine have to concentrate on

two major areas like clinical stability and kinematics. Stability as it

applies to the spine, which may be defined as the ability of the spine

under physiologic loads of limit patterns of displacement.

17

Damage or irritation of the spinal cord and nerve roots in addition,

to prevent incapacitating deformity (or) pain due to structural changes,

while the issue of clinical instability is particularly germane to traumatic

injuries of cervical spine, the subject also applies to inflammatory

disorders such as rheumatoid arthritis and degenerative spondylolisthesis.

Range of motion in the sub axial cervical spine can be helpful in making

decisions about instability. The maximum anteroposterior translation on a

lateral radiograph under physiologic loads has been measured. A

difference in angulations greater than 110 between two cervical segments

on a lateral radiograph also suggests abnormal motion.

Kinematics is the examination of the motion of bodies without

consideration of the influencing forces. The two factors that determine

the kinematics of vertebral motion are the geometry of the articulating

surfaces and the mechanical properties of the connecting structures. The

function of cervical spine may be divided into two sections, that of the

upper segment above C3 and that of the lower segment from C3 to C7.

Most of the axial rotation in upper cervical spine occurs at the

atlantoaxial joint.

The articular surfaces are convex with a horizontal orientation,

allowing for maximum mobility. Atlantoaxial rotation averages 470,

18

which represents about 50% of the axial rotation in the neck, with the

lower cervical spine contributing the other 50% of rotation. There are also

about 40 of axial rotation at the occipito cervical junction. The rotation of

C2 on C3 is physically limited by the anatomic locking of the anterior tip

of the articular process of C3 on the lateral process of the axis. The lower

cervical segment includes C3 through C7 with foraminal openings for the

spinal nerve roots that supply the upper extremities. Motion in the lower

cervical spine includes flexion, extension, lateral flexion, and rotation.

In forward flexion, the anterior disc space undergoes compression

with widening posteriorly simultaneous separation and shear of the

posterior elements occur. An anterior shearing force is placed on the disc

with elongation of annular fibrosis. Forward gliding of superior vertebrae

occurs on the inferior vertebrae with widening of facet joint. In extension

of the cervical spine, the posterior aspect of the disc compresses and the

anterior portion elongates. The facet joint glides posteriorly positions of

the cervical spine affect intra discal pressure. In supine it is least and in

extension it is greatest.

Flexion of the cervical spine is limited by the posterior longitudinal

ligament, the posterior inter vertebral ligaments that attach to the

transverse processes, posterior superior spine and the limited elasticity of

the fascia of the extensor musculature excessive extension is limited by

19

direct contact of the vertebral laminae, zygapophyseal joints and the

posterosuperior Spinous process.

As the neck flexes the spinal canal lengthens with the posterior

wall elongating to a greater degree than the anterior wall. Conversely

when the neck extends, the canal shortens, with the anterior wall. The

spinal cord ascends and descends in the spinal canal as the neck is flexed

and extended posture is a neuromuscular reaction to proprioceptive

impulses from the periphery and the feeling that posture is appropriate is

a learned process. The posture will be considered normal by the nervous

system even if the places the musculoskeletal system at a mechanical

disadvantage. In later life these positions may result in fatigue and neck

pain.

NECK DISABILITY INDEX

Neck Disability Index questionnaire is used to measure the level of

neck pain, which was modeled after the Oswestry questionnaire by

Vernon and Mior in 1991. Similar to Oswestry, subjects choose the

statement that best describes the situation in each of the ten sections. The

section is concerned with impairments like pain intensity, personal care,

lifting, reading, sleeping, concentration, work, driving, sleeping, and

20

recreation. Total score can range from 0 to 50 where 0 is considered as

highest level of function and 50 has lowest level of function.

MUSCLE HOLDING CAPACITY

Muscle holding capacity is used to measure the holding capacity of

low load, inner range isometric contraction of the muscle.

CRITERIA FOR MECHANICAL NECK PAIN 7

Pain is usually cyclic and episodic.

Morning stiffness or pain is common.

There is pain on forward flexion and often also on returning to

erect position.

Pain is often produced or aggravated by extension, lateral flexion,

rotation and exercises.

Pain usually becomes worse over the course of the day.

Pain is relieved by change of position especially when lying down

or in flexed Posture.

Νeck pain lasting more than one day.

21

NEED FOR THE STUDY

“Pleasure is often a visitant but pain cruelly clanged on us” kart M.

Pain is defined as the sensory, emotional experience associated

with actual (or) potential damage to the tissues, it is predicted that

prevalence rate of neck pain will continue to rise as the computers have

made a sweeping and drastic change in our working environment. These

complaints are often grouped together as occupational overuse syndromes

(or) work related neck disorders.

Mechanical neck pain remains an almost universal condition.

Mechanical Neck

pain is a descriptive term commonly used for a mechanically originating,

non- discogenic

Neck pain, which is provoked by physical activity and relieved by rest.

This is a chronic

dull aching pain of varying intensity affecting the spine.

In general terms poor and sustained postures and repetitive and

static activity of the neck are considered provocative factors for neck

pain. Jull 2000 demonstrated impairment in the deep cervical muscles,

which are considered to be functionally important for joint support and

22

control. Deficits in muscle coordination which could result in poor

support and potential overload on cervical structures.

Mayoux et al (1994) highlighted the importance of longus colli for

postural control of the cervical curve. Beeton and Jull in 1994 found that

there is a evidence that the upper and deep cervical flexors tend to lose

their endurance capacity in patients with neck pain.

Effective management of this condition is vital not only for the

relief of symptoms but perhaps more importantly, for the prevention of

recurrent episodes of cervical pain personal suffering and lost work

productivity. A number of studies have demonstrated a reduction in the

strength and endurance capabilities of both deep and superficial cervical

flexes muscles in patients with neck pain.

Exercise interventions are important for effective management of

patients with neck pain. However there is a consensus on optimal exercise

prescription.

The increased understanding of the tonic supporting role of the

deep neck flexors and their functional differentiation from the superficial

flexors realizes the need to develop a test that would target these muscles

in relative isolation from their superficial counterparts. To test this

23

hypothesis a low load craniocervical flexion test has been developed by

Jull et al to investigate the anatomical action of the deep cervical flexors,

specifically of the longus colli in synergy with the longus capitis.

Various methods are used to treat patients with neck pain. These

include exercise therapy, massage, ergonomic advice, electrotherapy,

short-wave diathermy and spinal manipulative therapy. Manipulative or

manual therapy is one of the fundamental treatment methods used by

physical therapists, osteopaths, chiropractors and manual medicine

practitioners in the management of neck pain.

There is evidence that manipulative therapy can be effective for the

relief of pain and restoration of motion in the short term, but this therapy

has not met the challenge of lessening persistent and recurrent episodes of

neck pain. This was also our clinical experience and, in addition, general

neck exercises appeared to have equal limitations for the goal of

controlling pain and preventing recurrent or persistent episodes of pain.

New direction in therapeutic exercise for spinal joint stabilization

has been developed over several years, its development involving clinical

problem solving and technical skills as well as basic and applied

scientific research. It was initially through studying how the muscles

24

could provide cervical segmental stabilization that insight was gained into

the type of therapeutic exercise that may be beneficial for supporting the

spinal joints, controlling pain and preventing recurrent bouts of neck pain.

Based on the available evidence on the spinal joint stabilization, I

intended to study stabilization programme using the muscle system to

protect the spinal joint structures from further repetitive micro trauma,

recurrent pain and degenerative changes. Pressure biofeedback is a device

designed to teach and measure various muscle functions. So using

pressure biofeedback which may be more beneficial in re-educating deep

neck flexors, which are the major small muscles directly attached to the

cervical vertebrae, and more prone to weakness in neck pain patients.

Using stabilizer pressure biofeedback the repeated practice of

exercise will enhance motor learning and therefore an exercise program

to perform during the days and during functional activities is essential.

Studies have proved that Isometric exercises or static exercises helps in

improving the muscle tension and strength without any movement in the

joint, and there by relieve neck pain by strengthening the deep neck

muscles. NDI Questionnaire has been designed to give the information as

to how the Neck pain has affected the patients ability in everyday life.

25

NDI is considered as a primary tool in this study, since all of its

components deals with pain and in this study pain is considered as a

primary problem. Hence in order to have an objective tool muscle holding

capacity is selected. Thus for retraining these muscles both the stabilizer

pressure biofeedback exercises and isometric neck exercises were used to

compare and to show the efficacy of reduction of pain by using NDI in

this study.

26

OBJECTIVES

To study the efficacy of stabilizer pressure biofeedback of Deep

Neck flexors helps in reducing chronic neck pain using Neck

Disability Index.

To study the efficacy of isometric exercises of Deep Neck flexors

helps in reducing chronic neck pain using Neck Disability Index.

To compare the results obtained by stabilizer pressure biofeedback

and isometric exercises of Deep Neck flexors in reducing chronic

neck pain using Neck Disability Index.

27

HYPOTHESIS

NULL HYPOTHESIS

There is no significant difference between the effectiveness of

stabilizer pressure biofeedback and isometric neck exercises of Deep

Neck flexors in reducing chronic neck pain using Neck Disability Index.

RESEARCH HYPOTHESIS

There is significant difference between the effectiveness of

stabilizer pressure biofeedback and isometric neck exercises of Deep

Neck flexors in reducing chronic neck pain using Neck Disability Index.

28

REVIEW OF LITERATURE

Falla D (2004)8 has analyzed deficits in the motor control of deep

and superficial cervical flexor muscles in people with chronic neck

pain.

Grand R J, Jull G A (1997)9 found that an exercise programme that

focuses on specific load training of key supporting muscles of the

neck and shoulder girdle has potential beneficial effects to upper

quadrant musculoskeletal system.

Ylinen J, Tkala (2003)10 Concluded in his study that strength and

endurance training with a 12 day institutional programme followed

by advice to exercise regularly at home were effective methods for

decreasing pain and disability in women with chronic neck pain.

Gustawa Stendig-Lindberg (2004)11 stated that daily application of

isometric exercise for 6 seconds only by using two thirds of

maximal contractile force, results in a optimal increase of muscle

strength.

Thomas Tai wing Chiu et al (2005)12 concluded that performance

on the CCFT by subjects with chronic neck pain was significantly

lower than that of a matched asymptomatic control group and

further results of the study adds to the evidence that poor ability to

29

perform the CCFT may be clinical evidence of an impairment that

characterizes neck pain, regardless of origin.

Dr. Deepak sharan (2001-2006)13 found that the age between 18 to

52 are usually affected by neck pain and the median age is 27

years.

Peter D Aker (1996)14 concluded that there is a little clinical data

available from clinical trails to support many of treatments for

mechanical neck pain and in general conservative interventions

have not been studied enough in detail to assess the efficacy (or)

effectiveness adequately.

Vernon (1991)15 demonstrated that the neck disability index has

achieved a high degree of reliability and internal consistency.

Panjabi (1998)16 stated that the osteoligamentous system

contributes 20% to the mechanical stability of the cervical spine

while 80% is provided by the surrounding neck musculature.

Janda (1994)17 suggests that the cervical flexors muscles become

dysfunctional in the presence of neck pain and further

demonstrated a reduction in the strength and endurance capabilities

of cervical flexor muscles in neck pain patients.

Cote (1998)18 estimated that 67% of individuals will suffer from

neck pain at some stage of life.

30

Merskey H (1986)19 stated that pain occurs (or) is associated with

actual (or) potential damage to the tissues.

Taimola (2000)20 stated that if the neck pain lasts for more than 3

months of duration is said to be chronic.

Chiu TT (2002)21have demonstrated a reduction in the strength and

endurance capabilities of both deep and superficial cervical flexor

muscles in patients with neck pain.

Mayoux (1994)22 highlighted the importance of longus colli for

postural control of cervical curve.

Beeton and Jull (1994)23 concluded that there is a evidence that the

upper and deep cervical flexor lose their endurance capacity in

patients with neck pain

Falla D, Jull G (2006)24 concluded that an endurance - strength

exercise regime for the cervical flexors muscles is effective in

reducing myoelectric manifestations of superficial cervical flexor

muscle fatigue as well as increasing cervical flexion strength in

group of patients with chronic non severe neck pain.

Moseley GL, Hodges PW (2005)25suggested that altered postural

adjustments of the trunk muscles during pain are nor caused by

pain interference but are likely to reflect development and adoption

of an alternate postural adjustment strategy, which may serve to

31

limit the amplitude and velocity of trunk excursion caused by arm

movement.

Panjabi MM (2003) 26found that the spinal muscles provide

significant stability to the spine as shown by both in vitro

experiments and mathematical models concerning the role of

neuromuscular control system, increased body sway has been

found in patients with low back pain, indicating a less efficient

muscle control system with decreased ability to provide the needed

spinal stability.

Peter white (2004)27 concluded that short core neck pain

questionnaire has been found to be valid as a brief neck disability

index questionnaire for use of patients with mechanical neck pain.

Michael S, Conley (1995)28 concluded from the results of his study,

has proved that few selected muscles which have been examined in

human electromyographic studies neck muscle function and

morphology can be studied at a detailed level using exercise

induced shifts in magnetic resonance images.

Deborah L Falla (2004)29 suggested few data which confirms that

reduced performance of the craniocervical flexion test is associated

with dysfunction of the deep cervical flexor muscles and supports

the validity of this test for patients with neck pain.

32

Pierre cot e (1998) 30in his cross sectional study shows that neck

pain is highly prevalent in Saskatchewan and that it significantly

disables 4.6% of the adult population.

Hodges and Richardson (1996-1997)31 suggested that specific

muscles with a muscle group have been found to be dysfunctional

they are the deep muscles h direct vertebral attachments that span

the vertebrae and have more influence on joint control rather than

torque production.

Watson and Trott (1993)32 suggested there is a clinical evidence

that the upper and deep cervical flexors that are important muscles

for cervical segmental and postural control lose their endurance

capacity in patients with neck pain.

Winters and Peles (1990)33 on studying the interaction of several

neck muscles by computer modeling, noted that if only the large

muscles of the neck were simulated to produce movement, this

resulted in regions of local segmental instability particularly in near

upright or neutral postures deep muscle activists was required to

stiffen (or) stabilize the segments in functional mid ranges.

Cholewicki and Mc Gill (1996)34 suggested that the deep muscles

of the neck which is attached directly to the vertebrae appears to

have a particular role for joint support.

33

Jull (1994)35 suggested that the holding capacity of the upper and

deep cervical flexors were determined by their ability to sustain an

inner range upper cervical flexion position in supine lying.

Jull G, Barrett C (1999)36 in his clinical use of the test suggests that

an ideal controlled performance of the deep cervical flexors can

increase the pressure to 30mmHg and hold this pressure for 10

seconds.

Falla et al (2003)37 demonstrated that an average 24.9% of the full

range of craniocervical flexion was used to reach the first target of

the CCFT (22mmHg) followed by linear increments up to 80% for

the last stage of the test (30mmHg).

34

MATERIALS AND METHODOLOGY

POPULATION

Chronic Neck pain subjects between 25-50 yrs of both genders

SOURCE OF DATA

Government General Hospital, Tamilnadu.

Padmavathi College of Physiotherapy, OPD, Dharmapuri.

Clinics in and around Dharmapuri.

SAMPLE SIZE

Sample size is 30

SAMPLING DESIGN

Simple Random Sampling

RESEARCH DESIGN

Experimental evaluation comparative study.

INCLUSION CRITERIA

Subject with Chronic neck pain

Subjects between the age of 25-50 years

Both genders

35

Subject with Mechanical neck pain

EXCLUSION CRITERIA

Acute cervical disc prolapse

Recent cervical vertebral Fracture

Recent ligament and muscle injuries in neck region

Subject with cervical spinal deformities

Subject with radiating pain along the upper limb and head

Subject with neurological problem.

Open wounds around neck.

Tumors of cervical origin

Vertebro Basilar Insufficiency

Recent dental fracture and conditions like mandibular fracture

MATERIALS

Stabilizer Pressure Biofeedback

Towel

Couch / Treatment Table

36

FIGURE 4

TOOLS

Neck Disability Index

Muscle Holding Capacity using stabilizer pressure

biofeedback

PROCEDURE

Subjects were selected randomly after getting informed consent

before starting the Treatment. The subjects are positioned comfortably

and assessed thoroughly about his/her condition. Pre treatment

37

assessment includes Neck Disability Index and Muscle Holding Capacity

was taken once in every week for four weeks, with treatment sessions

carried out thrice every week.

Subjects are divided into two groups by Random sampling method.

Group A- Stabilizer pressure biofeedback

Group B- Isometric Exercise

Group A was treated with SPB in supine lying with Chin tuck in, to

strengthen the deep neck flexors for 10 sec hold for 10 repetitions for 4

weeks duration

Training of Deep Neck Flexors using SPB

Patient lies supine with the head and cervical spine in neutral

position. A folded towel may be placed beneath the patient head to obtain

neutral position if necessary. The patient is instructed to place the tip of

the tongue on the roof of the mouth and keep the jaw relaxed this

prevents the patient from fixing the jaw and substituting the hyoid

muscles.

Inflate the SPB to a baseline of 20 mm Hg and squeezed several

times to distribute the air in the bag evenly. If the pressure drops after

distributing the air in the bag it should be readjusted to the baseline

38

pressure. Position the 3 folded pressure cell under the neck so that it abuts

against the occiput and reading should be checked to maintain it in 20

mm Hg. The movement patient has to perform is a gentle nodding of the

head, as if they are saying ‘Yes’. Instruct the patient to gently nod and

just one mark on the pressure dial and see if the patient can hold the

position steadily. If successful relax and repeat at each target position up

to 30 mm Hg, Hold for 10 sec breathe normally. Perform 10 repetitions

each, twice daily, three days per week for four weeks38 39.

Group B was treated with Isometric exercises in supine lying with

Chin tuck in, to strengthen the deep neck flexors for 6 sec hold for 10

repetitions for 4 weeks duration

Training of Deep Neck Flexors using Isometric Neck Exercise

The patient is asked to lie in supine position and head placed in

neutral position, then by placing the rolled towel behind the neck and

instruct the subject to perform slight chin tuck and then press the towel

placed behind the neck and hold the contraction for 6 sec without any

movement. Perform 10 repetitions, twice daily, three days per week for

four weeks40, 41, 42.

Each week NDI and Muscle holding capacity is recorded in each

group respectively.

39

RESULTS

RESEARCH DESIGN

A Experimental evaluation comparative study consisting of 30

patients with Neck pain randomized in to two groups; 15 subjects in

Group A (Stabilizer Pressure Biofeedback) and 15 subjects in Group B

(Isometric Exercise) is undertaken to study and compare the effects of

treatment in reducing the neck pain.

TABLE 1

AGE AND SEX DISTRIBUTION

Age and sex

distribution Group A Group B

P value and

Remark

Number 15 15 -

Age in years

(Mean ± SD)

32.40 ± 6.54

(25-50)

31.60 ± 6.10

(26-45)

P=0.732

Samples are

age matched

Sex

Male=10

(66.7%)

Female=5(33.3

%)

Male=6(40.0%

)

Female=9(60.0

%)

P=0.143

Samples are

sex matched

40

FIGURE 7

05

1015202530354045

Group A Group B

Age

in y

ears

FIGURE 8

Male67.7%

Female33.3%

Group A

Male40.0%

Female60.0%

Group B

41

TABLE 2

NECK DISABILITY INDEX

Study period

Neck disability Index

Mean ± SD (Min-Max)

P value by

Student t

test Group A Group B

Week1 18.13±4.37

(10-24)

19.60±2.95

(16-24) 0.291

Week2 12.93±4.71

(6-20)

14.80±4.52

(8-22) 0.278

Week3 8.13±3.42

(4-16)

9.33±3.90

(4-16) 0.378

Week4 3.33±3.24

(2-10)

5.33±3.59

(6-10) 0.121

P value by

Repeated

measures ANOVA

P<0.001 P<0.001 -

% Change 81.63% 72.81% -

# Analysis of Covariance has been used to find the significance NDI at

Week 4 taking into account of variations at Week1, week2 and Week3.

42

FIGURE 9

0

5

10

15

20

25

Week 1 Week 2 Week 3 Week 4

Nec

k di

sabi

lity

inde

x

Group AGroup B

FIGURE 10

0

5

10

15

20

25

Week 1 Week 2 Week 3 Week 4

Nec

k di

sabi

lity

inde

x

Group AGroup B

43

TABLE 3

MUSCLE HOLDING CAPACITY

Study period

Muscle holding capacity

Mean ± SD (Min-Max)

P value by

Student t

test Group A Group B

Week1 22.00±1.51

(20-24)

22.27±1.98

(20-26) 0.682

Week2 24.93±1.49

(22-28)

24.53±1.77

(22-28) 0.508

Week3 27.73±1.67

(24-30)

26.93±1.28

(24-28) 0.152

Week4 29.33±0.98

(28-30)

28.27±1.49

(26-30) 0.028*

P value by

Repeated Measures

ANOVA

P<0.001** P<0.001** -

% Change 33.32% 26.94% -

# Analysis of Covariance has been used to find the significance MHC at

Week 4 taking into account of variations at Week1, week2 and Week3.

** Significant at P<0.001 (highly significant)

44

FIGURE 11

0

5

10

15

20

25

30

35

Week 1 Week 2 Week 3 Week 4

Mus

cle

hold

ing

capa

city

Group AGroup B

FIGURE 12

0

5

10

15

20

25

30

35

Week 1 Week 2 Week 3 Week 4

Mus

cle

hold

ing

capa

city

Group AGroup B

45

TABLE 4

COMPARISON OF NDI BETWEEN TWO GROUPS

Study

Period Group

Neck Disability Index

Normal Mild

Disability

Moderate

disability

Severe

disability

Complete

disability

Week 1

Group A

(n=15) - 2(13.3%) 13(86.7%) - -

Group B

(n=15) - - 15(100.0%) - -

Week 2

Group A

(n=15) - 10(66.7%) 5(33.3%) - -

Group B

(n=15) - 9(60.0%) 6(40.0%) - -

Week 3

Group A

(n=15) 3(20.0%) 11(73.3%) 1(6.7%) - -

Group B

(n=15) 1(6.7%) 11(73.3%) 3(20.0%) - -

Week 4

Group A

(n=15) 12(80.0%) 3(20.0%) - - -

Group B

(n=15) 9(60.0%) 6(40.0%) - - -

46

FIGURE 13

0

10

20

30

40

50

60

70

80

90

100

Perc

enta

ge

Group A Group B Group A Group B Group A Group B Group A Group B

Normal Mild disability Mod.disability

Week 1 Week2 Week3 Week4

Neck disability index

47

TABLE 5

COMPARISON OF NDI INDIVIDUAL TASKS BETWEEN TWO

GROUPS

Tasks Group

Study period

Week1 Week2 Week3 Week4

Mean ± SD

(Median)

Pain intensity

A 2.60±0.74

(2)

2.00±0.66

(2)

1.53±0.64

(1)

0.73±0.59

(1)

B 2.81±0.74

(3)

2.13±0.92

(2)

1.33±0.49

(1)

1.00±0.54

(1)

Personal care

A 2.67±0.72

(3)

1.93±0.79

(2)

1.40±0.63

(1)

0.27±0.46

(0)

B 2.93±0.70

(3)

2.13±0.92

(2)

1.07±0.59

(1)

0.53±0.52

(1)

Lifting

A 2.47±0.83

(3)

1.87±0.64

(2)

1.13±0.64

(1)

0.53±0.52

(1)

B 2.47±0.92

(2)

2.09±0.79

(2)

1.20±0.56

(1)

0.60±0.63

(1)

Reading

A 2.13±0.64

(2)

1.67±0.90

(2)

0.73±0.70

(1)

0.20±0.41

(0)

B 2.53±0.74

(2)

2.07±0.70

(2)

1.07±0.70

(1)

0.40±0.63

(0)

Headache A 0 0 0 0

B 0 0 0 0

Concentration A 2.60±0.51

(3)

1.40±0.74

(1)

0.80±0.78

(1)

0.27±0.59

(0)

48

B 2.33±0.49

(2)

1.80±0.68

(2)

1.20±0.56

(1)

0.60±0.74

(0)

Work

A 2.20±0.68

(2)

1.80±0.68

(2)

1.27±0.46

(1)

0.80±0.68

(1)

B 2.13±0.35

(2)

1.73±0.70

(2)

1.20±0.41

(1)

0.87±0.52

(1)

Driving

A 1.20±1.20

(2)

0.60±0.91

(0)

0.40±0.63

(0)

0.20±0.41

(0)

B 2.07±0.26

(2)

1.53±0.74

(2)

1.00±0.66

(1)

0.40±0.51

(0)

Sleeping A 0 0 0 0

B 0 0 0 0

Recreation

A 2.27±0.70

(2)

1.67±0.72

(2)

0.87±0.64

(1)

0.33±0.62

(0)

B 2.27±0.46

(2)

1.73±0.59

(2)

1.27±0.46

(1)

0.87±0.64

(0)

49

STATISTICAL METHODS

Chi-square / Fisher Exact test has been used to find the significance

of Neck disability Index between Group A and Group B during the study

period. Student t test (Two tailed) has been used to find the significance

of Neck disability Index and Muscle holding capacity between Group A

and Group B. Repeated Measures ANOVA has been used to find the

significance of Neck disability Index and Muscle holding capacity during

the study period for each group separately.

1. Chi-Square Test

EiEiOi∑ −

=2

2 )(χ , Where Oi is observed frequency and Ei is Expected

frequency

2. Fisher Exact Test

TABLE 6

Class1 Class2 Total

Sample1 a b a + b

Sample2 c d c + d

Total a + c b + d N

50

Fisher Exact Test statistic= ∑∑ ++++

=!!!!

1!

)!()!()!()!(dcban

dbcadcbap

3. “t” –test for two population means ( variance unknown but equal)

Objective: To investigate the significance between the means of two

populations

)2/11/1(

)()(2

2121

nns

xxt

+

−−−=

μμ

Where 221

)22()12()11()11(2

1

221

12

−+

−−+−−=

∑∑−=

nn

xxnxxns

n

i

n

i

4. ANACOVA: Analysis of Covariance has been used to find the

significance of difference of post treatment between groups keeping the

Pre treatment scores as covariates.

Procedure is as follows

SPT=∑∑ −N

TxTyxy , y is post treatment scores and x is Pre treatment

scores

51

SPB = N

TxTyni

TxiTyi−∑

SPW = SPT-SPB

SS`YT = SSyt - xt

T

SSSP 2

: SS`YW = SSYw - XW

W

SSSP 2

: SS`YB = SS`YT - SS`YW

ANACOVA TABLE

TABLE 7

Source of

variation

df

SSx

SP

SSy

SS`y

MSS`y

F ratio

Between

groups (k-1) SSXB SPB SSYB SS`YB MSS`YB F

Within

groups (N-k-1) SSXW SPW SSYW SS`YW MSS`YW -

Total (N-2) SSXT SPT SSYT SS`YT - -

Total number of subjects taken for the study N = 30. The total

number of subjects in Group A = 15 (male 10, female 5) with the mean

age of 32.40 + 6.54.The total number of subjects in Group B = 15 (male

6, female 9) with the mean age of 31.60 + 6.10.

52

There is no significant difference between age and sex distribution

between the Group A and Group B

Comparison of decrease of NDI between Group A and Group B

There is a significant decrease of NDI to 3.33 in Group A which is

much lower when compared to Group B 5.33, with p = 0.169#. Hence

research or alternate hypothesis is accepted.

Comparison of NDI individual tasks between 2 groups

There is significant difference in all individual tasks expect in

headache and sleeping components.

Comparison of increase of MHC between Group A and Group B

MHC is significantly increased in Group A which when compared

to Group B with p = 0.006.

STATISTICAL SOFTWARE

The Statistical software namely SPSS 11.0 and Systat 8.0 were

used for the analysis of the data and Microsoft word and Excel have been

used to generate graphs, tables etc 43,44.

53

DISCUSSION

This study is an attempt to assess the efficacy of stabilizer pressure

biofeedback and isometric exercise to reduce chronic neck pain by

activating the deep neck flexor muscles in chronic neck pain subjects.

Patients with chronic neck pain who were treated with stabilizer

pressure biofeedback (Group A) have shown statistically better

improvements in reduction of pain and muscle holding capacity than the

isometric exercise (Group B). The design of the study (which include

random assignment to study group)

The effect of the treatment were achieved in four weeks of duration

that most probably due to the effective activation of deep neck flexors.

Most of previous studies suggested that in neck pain patients, deep neck

flexors activation is decreased and also the muscle holding capacity is

reduced.

Jull G stated that the anatomical interrelated action of the deep

neck muscles are to support and stabilize the cervical.

Janda in his study stated that cervical flexor muscles become

dysfunctional in the presence of neck pain and demonstrated that there is

reduction in the strength and endurance capabilities of cervical flexor

muscles in neck pain patients.

54

Watson and Trott stated that the upper and deep cervical flexors

contraction is important to stabilize the spine by creating a tension over

the cervical fascia. In turn this stabilizes the cervical spine and forms

stable base for the movement and functional activities. The current study

was focused on generalized neck pain, mechanical in origin.

Beeton and Jull stated that deep neck flexors are the key muscle for

the stabilization of the cervical spine. There is a significant dysfunction of

this muscle has also been implicated in neck pain patients.

Hence the deep neck flexors help in improving the strength and

there by relieve chronic neck pain. SPB was proved as a preventive

measure, retraining the stabilization capacity of the deep neck flexors

might reduce the effect of cervical structures from stress. Chi Square Test

/ Fisher Exact Test have been used to find the significance of NDI

between Group A and Group B the study period. Student t test has been

used to find the significance of difference of pre and post set groups

keeping the NDI and MHC during the study period for each group

separately.

The improvements in NDI mean standard deviation difference is

reduced to (3.33) in Group A which is much lower when compared to

55

Group B (5.33) with p=0.169 by ANACOVA test. Improvement in MHC

is significantly increased in Group A which when compared to Group B

with the p=0.006** by ANACOVA test.

The percentage reduction of NDI also significantly reduced in

Group A (80%) compared with Group B (60%). test. When individual

components are compared between Group A and Group B, the Pain

intensity, personal care, reading, concentration, driving and recreation

components shows marked improvement in reduction of NDI value at the

end of 4th week and there is more difference is seen in between the values

of Group A and Group B. when comparing components of lifting and

work there is marked reduction in the NDI value but the difference

between the groups is less, and components of Headache and sleeping has

equal score of Zero from the initial procedure, Since the mechanical neck

pain relieves during rest and headache is excluded from the study.

The design of this study precludes determination of which aspect

of the treatment program produced the changes in neck pain.

This study result had not been influenced by the age characteristics,

because the Mean +SD are almost equal in NDI of both the groups.

56

Both the Groups showed significant improvement in first two

weeks and third and fourth week Group B has shown slight improvement

it may be due to isolation of specific muscle group contraction, motor

control and relearning due to visual feedback. Increase in isometric group

may be due to involvement of other global muscles. when comparing

NDI and MHC of both the groups , Group A showed significantly better

improvement due to visual biofeedback.

This study also coincides with Grant Jull who states that the

stabilizer pressure biofeedback is more significant in isolating the Deep

neck flexors muscles specifically and there by relieve neck pain.

This study may show marked significant changes in statistical and

theoretical aspect when carried out for a longer duration.

Stabilizer pressure biofeedback may help in the learning process of

muscular control and helps in improving the joint stability. Biofeedback

may be contributed to the increased force by motor unit recruitment or by

increasing firing rates in the active motor units. Basmajian has stated that

by the help of the visual signals, patients could control the recruitment as

well as the frequency of discharge of motor units, which could produce

the great amount of tension.45

57

Isometric exercises also help in reducing neck pain, but the effect is

little bit slow compared to SPB, Since Stabilizer pressure biofeedback has

proven to be effective treatment measure in reducing chronic neck pain.

LIMITATIONS

The outcome measure was only neck disability index and

muscle holding capacity.

Study population is selected only from Bangalore.

Confounding variables like Range of motion, postural

adjustment are not used.

Manipulation technique was not considered.

Only isometric exercise was given with an emphasize to

strengthen deep neck flexor exercise.

58

RECOMMENDATIONS AND SUGGESTIONS

This study revealed only with deep flexors muscles, other

muscle groups also can be considered in further studies in

reducing neck pain.

The same study may be explored for specific neck pain

conditions

This study can also be done for radiating pain conditions.

The beneficial treatment effect can be followed for the

persistence of recovery

The present study may be done in larger population for better

outcomes

The study was focused in supine lying position only. This can

also be done in other functional positions

The study can be carried out for longer duration to show better

results.

This study can be further carried out in combination of both

treatment.

59

CONCLUSION

This study concluded that the SPB have better improvement in

reduction of pain by giving correct feedback for the isolation of deep

neck flexors contraction in chronic neck pain patients with the help of

NDI score. From this study it is also noted that the basic

characteristics of age and sex are not having a direct impact on chronic

neck pain subjects.

SUMMARY

The study is done to find out the comparison of stabilizer pressure

biofeedback and isometric exercise for reduction of pain by

contracting the deep neck flexors in chronic neck pain subjects with

the help of NDI value.

This study included thirty pain subjects between the age group of

25-50 years ,they are divided into two groups randomly (A &B

Experimental groups).Group A were treated with stabilizer pressure

biofeedback and Group B were treated with isometric neck exercise.

Group A was treated with 10 sec hold for 10 repetitions twice daily,

three times a week. Group B was treated with 6 sec hold for 10

60

repetitions twice daily, three times a week. Study design is

experimental evaluation comparative study. Sources of data collected

from Victoria hospital, Bangalore. Sathya hospital Bangalore and

physiotherapy and physical rehabilitation center, the oxford college of

physiotherapy. Group A were shown statistically better improvement

in neck disability index at p=0.162# and significant increased in

muscle holding capacity with the p=0.006**# when compared with

group B isometric exercise. This study shows that the stabilizer

pressure biofeedback is effectively good and statistically significant in

reduction of pain and increase of muscle holding capacity for patients

with chronic neck pain.

61

REFERENCES

1. Seeley Stephen, Anatomy and physiology, 5th edition, Tate 2000.

2. Bernstein Wiesel boden, Neck pain medical drug and comprehension

management 2001.

3. Harms Ringdahl K, Ekholm J Schuldtk, Nemoth G, Arborelius, Load

movements and myoelectric activity when the cervical spine is held in

full flexion and extension. Ergonomics;1986:29(12): 1539-1552

4. Jull G. Deep cervical flexor muscle dysfunction in whiplash

musculoskeletal pain; 2000:8:143 -154.

5. Comer fords MJ, Mott ram SL, Functional stability retraining:

Principles and strategies for managing mechanical dysfunction.

Manual Therapy 2001;6(1):3-14

6. Carr J and Shepherd R B ,A motor relearning programme for stroke

London :William Heinemann;1987: pp29-33

7. David J, Magee, Orthopedic physical assessment, published by W B

Saunders;1997

62

8. Falla D. Unraveling the complexity of muscle impairment in chronic

neck pain. Manual therapy; 2004:9:125-133.

9. Grant RJ , Jull GA and Spencer TJ :Active stabilization training for

screen based key board operators a single case study , Australia

Journal of physiotherapy;1997: 43: 235-242

10. Ylinen J, Tkala. Active neck muscle training in the treatment of the

chronic neck pain in women, a randomized controlled trial. JAMA

;2003:No289: pp2509-2516

11. Gustawa Stendig. Therapeutic exercises, E medicine :2004

12. Thomas Tai Wing. Performance of the craniocervical flexion test in

subjects with and without chronic neck pain: Orthop sports phys ther;

2005:vol 35: pp 567-571

13. Dr. Deepak Sharan, Repetitive strain injuries, incidence of mechanical

neck pain in Bangalore 2001-2006

14. Peter D Aker, Conservative management of mechanical neck pain;

systemic overview and meta analysis BMJ ;1996: Vol 313;No

23:1291-1296

63

15. Vernon H, The Neck disability index :A study of reliability and

validity: journal of manipulative physiol ther;1991: Vol 14:No

7:pp409-415

16. Panjabi M M, Chole wicki J, Nibu K, Critical load of the human

cervical spine: an in vitro experimental study. Clinical biomechanics

;1998:13:11-17

17. Janda V Muscles and motor control in cervicogenic disorders:

assessment and management .In grant R ,editor .physical therapy of

the cervical and thoracic spine.newyork:Churchill Livingstone

;1994:195-216

18. Cote P, Cassidy J D, Carroll L, The Saskatchewan health and back

pain survey, the prevalence of the neck pain and relative disability in

Saskatchewan adults. Spine 1998:23(15):1689-1698.

19. Merskey H “Classification of Chronic pain: Description of chronic

pain syndromes and definitions of pain terms 1986

64

20. Taimola S, Takala E P, Asklof T, Active treatment of chronic neck

pain: A prospective randomized intervention. Spine 2000; 25:1021-

1027

21. Chiu T T, Losk. Evaluation of Cervical range of Motion and Isometric

neck muscle strength: reliability and validity .Clin Rehabil; 2002:

16:851-858.

22. Mayoux-Benhamou MA, Reval M et al. Longus colli has a postural

function of cervical curvature. Surgical and radio logic anatomy;

1994:16:367-371.

23. Beet on and Jull, Effectiveness of manipulative physiotherapy in the

management of cervicogenic headache single case study

physiotherapy; 1994:80:417-423.

24. Falla D. Unraveling the complexity of muscle impairment in chronic

neck pain. Manual therapy; 2004:125-133

25. Moseley GL and Hodges PW. Are the changes in postural control

associated with pain caused by pain inference? Clin J pain; 2005:

21(4):323-329.

65

26. Panjabi MM, Clinical spinal instability and low back pain .J

Electromyography and kinesiol.2003; 13(4):71-79.

27. Peter white. The core outcomes for neck pain: Validation of a new

outcome measure. Spine 2004: Vol 29:No17;1923-1930

28. Conley B et al, non invasive analysis of human neck muscle function.

Spine1995: 20:2505-2512

29. Deborah L Falla. Patients with Neck pain demonstrate reduced electro

myographic activity of deep cervical Flexor muscles during

performance of the craniocervical flexion test. Spine 2004: Vol 29; No

29: pp 2108-2114.

30. Pierre Cote DC,MSC, J .David Cassidy.The saskatchewen health and

back pain survey:The prevalence of neck pain and related disability in

Saskatchewan adults.Spine1998:Vol23;No15:pp1689-1698.

31. Hodges PW, Richardson CA. Delayed postural contraction of

transversus Abdominis in low back pain associated with movement

of the lower limb. Spinal Disord; 1998:11(1):46-56.

66

32. Natural head posture and upper cervical flexor muscle performance.

Cephalgia; 1993:13: pp 272-284.

33. Winters J M, Peles J D. Neck muscle activity and 3D head kinematics

during quasistatic and dynamic tracking movements. In: winters J M,

Woo S L editors. Multiple muscle systems: Biomechanics and

movement organization. New York: Springer; 1990: pp 461-480.

34. Cholewicki J and McGill S, mechanical stability of the in vivo lumbar

spine: Implication for injury and chronic low back pain. Clinical

biomechanics; 1996: 1-15.

35. Jull G .Physiotherapy management of the cervical spine .In Giles L,

Singer K. clinical anatomy and management in cervical spine pain,

UK: Butterworth Heinemann; 1998:168-197.

36. Jull G Barrett C, Magee R, HO P. Further clinical classification of the

muscle dysfunction in cervical headache. Cephalgia 1999:19:179-185.

37. Falla D, Jul G, An electro myographic analysis of the deep cervical

flexor muscles during craniocervical flexion. Physical therapy;

2003:83:899-906.

67

38. H. Duane Saunders and robin Saunders Ryan, Evaluation, treatment

and prevention of musculoskeletal disorders, Spine; 2004, vol 1,

39. Ruth grant, Clinics in physical therapy of the cervical and thoracic

spine, published by Churchill Livingstone, New York; 1997.

40. Carrie M Hall, Lori Thein Brady, Therapeutic exercises moving

towards to function; 1998: pp 532.

41. M D Robert, H Shmerling, what to do about Neck pain, Harvard

medical school 2000

42. Carolyn Kishner, Lynn Allen Colby. Therapeutic exercises foundation

and techniques 4th edition published by Jaypee brothers, New Delhi;

2002: pp 80-83

43. Bernard Rosner, Fundamentals of Biostatistics, 5th Edition, Duxbury

2000.

44. M. Venkataswamy Reddy, Statistics for Mental Health Care Research

NIMHANS Publication, India 2002.

45. Basmajain J. Control and training of individuals motor units, science;

1963: 440-441.

68

APPENDICES

ANNEXURE I

INFORMED CONSENT FORM

TITLE

Comparison of Stabilizer pressure biofeedback and Isometric Neck

exercises in reducing Chronic Neck pain using NDI.

PURPOSE OF THE STUDY

I ……………………………have been informed by Mr. M.

Sitharthan that this study is done to find out stabilizer pressure

biofeedback/Isometric Neck exercise will reduce pain, this study has role

to play in reducing Chronic Neck pain and improve my function by

reducing the disability.

PROCEDURE

I understand that I will be randomized and put into one of the

exercise protocol, either stabilizer pressure biofeedback for 10 sec hold

for 10 repetitions or Isometric exercises for 6 sec hold and 10 repetitions.

I will be explained about the intensity at which I have to perform the

exercises. I also understand that I will work out the exercises under the

69

supervision and guidance of Mr. M. Sitharthan and follow the instructions

given by her.

RISK AND DISCOMFORT

I understand that there is no potential risk associated with the

treatment programme, and I will not experience any discomfort during

the exercises.

I understand that Mr. M. Sitharthan will accompany me during the

Treatment

BENEFITS

The Stabilizer pressure biofeedback and Isometric Neck exercises

will help in reducing pain

ALTERNATIVES

Other treatment alternatives are explained to me with their benefits

and limitations.

CONFIDENTIALITY

I understand that the information produced by this study will be

confidential. If the data are used for publication in the medical literature

or for teaching purpose, no names will be used and other literatures such

70

as photographs and audio or video tapes will be used only with

permission

71

REQUEST FOR MORE INFORMATION

I understand that I may ask any question about the study at any

time to Mr. M. Sitharthan and she is available to answer my question.

Copy of this concern form will be given to me to keep for my careful

reading

REFUSAL OR WITHDRAWAL OF PARTICIPATION

I understand that my participation is voluntary and I may refuse to

withdraw consent and discontinue participation at any time. I also

understand that she may terminate my participation in the study at any

time after she has explained the reasons for doing so

INJURY STATEMENT

I understand that the exercises which I am going to perform are

most unlikely to cause any injury or further deteriorate my condition if

performed under the guidance of Mr. M. Sitharthan. In such case medical

attention will be provided, but no further compensation will be provided.

I understand my agreement to participate in this study and I am not

waiving any of my legal rights.

I confirm that Mr. M. Sitharthan has explained me about

the purpose of the study, the study procedure and the possible risk and

benefits that I may experience. I have read and I have understood this

concern to participate as a subject in this study

72

………………

………………

SUBJECT

DATE

………………………..

………………

WITNESS TO SIGNATURE

DATE

I have explained to sri /smt…………………………………..the

purpose of the research, the procedure required and the possible risks and

benefits, to the best of my ability.

………………….

……………

INVESTIGATOR

DATE

73

ANNEXURE II

ASSESSMENT PROFORMA

o Patient Name :

o Age :

o Sex :

o Occupation :

o Address :

o Study setup/ Source :

o Presenting Complaint :

o Past History :

o Personal History :

o Occupational History :

o Subjects with Age group 25-50 : Yes / No

o Subjects with Chronic Mechanical Neck pain : Yes / No

o Subjects with cervical vertebral fractures : Yes / No

o Subjects with cervical dislocations : Yes / No

o Subjects with Radiating pain to upper limb and head : Yes / No

o Subjects with TMJ dysfunction: Yes / No

o Subjects with Tumor of cervical origin : Yes / No

o Subject with Recent ligament and muscular tears : Yes / No

o Subjects with migraine : Yes / No

74

o Subjects with Migraine : Yes / No

o On Observation :

o On palpation :

o On Examination :

Neck Disability Index

Week 1 2 3 4

Stabilizer

Pressure

Biofeedback

Isometric

Exercise

Muscle Holding Capacity

Week 1 2 3 4

Stabilizer

Pressure

Biofeedback

Isometric

Exercise

o Spurling / Compression Test : Positive / Negative

o VBI Test : Positive / Negative

o Investigations :

75

o Diagnosis :

o Management :

76

ANNEXURE III

NECK DISABILITY INDEX

1.PAIN INTENSITY

o I’ve no pain at the moment o The pain is very mild at the

moment o The pain is moderate at the

moment o The pain is fairly severe at the

moment o The pain is very severe at the

moment o The pain is the worst

imaginable at the moment

2.PERSONAL CARE(Washing, Dressing) etc

o I can look after myself normally without causing extra pain

o I can look after myself normally, but it causes extra pain

o It is painful to look after myself, I am slow and careful

o I need some help but manage most of my personal care

o I need help every day in most aspects of self care

o I don’t get dressed, wash with difficulty and stay in bed

3.LIFTING

o I can lift heavy weights without extra pain

o I can lift heavy weights but it gives me extra pain

o Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned, for example on a table

o Pain prevents me from lifting heavy weights but I can manage light to medium weights if they are conveniently positioned

o I can lift very light weights o I cannot lift or carry anything

at all.

4.READING

o I can read as much as I want to with no pain in my neck

o I can read as much as I want to with slight pain in my neck

o I can read as much as I want with moderate neck pain

o I can’t read as much as I want because of moderate neck pain

o I can hardly read at all because of severe pain in my neck

o L cannot read at all

77

5.HEADACHES

o I have no headaches at all o I have slight headaches which

come in frequently o I have moderate headaches which

come infrequently o I have moderate headaches which

comes frequently o I have severe headaches which

comes frequently o I have headaches almost all the

time

6.CONCENTRATION

o I can concentrate fully when I want to with no difficulty

o I can concentrate fully when I want to with slight difficulty

o I have fair degree of difficulty in concentrating when I want to

o I have a lot of difficulty in concentrating when I want to

o I have a great deal of difficulty in concentrating when I want to

o I cannot concentrate at all

7.WORK

o I can do as much work as I want

to do

o I can only do my usual work, but

no more

o I can do my usual work, but no

more

o I cannot do my usual work

o I can hardly do any work at all

o I can’t do any work at all

8.DRIVING

o I can drive my car without any neck pain

o I can drive my car as long as I want with slight pain in my neck

o I can drive my car as long as I want with moderate pain in my neck

o I can’t drive my car as long as I want because of moderate pain in my neck

o I can hardly drive at all because of severe pain in my neck

o I can’t drive my car at all

78

9.SLEEPING

o I have no trouble sleeping o My sleep is slightly disturbed(less

than 1 hr. sleepless) o My sleep is mildly disturbed(1-2

hrs. sleepless) o My sleep is moderately disturbed

(2-3 hrs. sleepless) o My sleep is greatly disturbed(3-5

hrs. sleepless) o My sleep is completely disturbed

(5-7 hrs. sleepless)

10. RECREATION

o I am able to engage in all my recreation activities with no neck pain at all

o I am able to engage in all my recreation activities. With some pain in my neck

o I am able to engage in most, but not all of my usual recreation activities because of pain in my neck

o I am able to engage in a few of my usual recreation activities because of pain in my neck

o I can hardly do any recreation activities because of pain in my neck

o I can’t do any recreation activities at all

SCORES (OUT OF 50)

0-4 = NO DISABILITY

5-14 = MILD DISABILITY]

15-24 = MODERATE DISABILITY

25-34 = SEVERE DISABILTY

ABOVE 35 = COMPLETE DISABILITY

79

MASTER CHART

STABILIZER PRESSURE BIOFEEDBACK

SL NO AGE SEX WEEK1 WEEK2 WEEK3 WEEK4

NDI MHC NDI MHC

NDI

MHC NDI MHC

1 40 F 16 22 10 26 8 30 4 30 2 25 F 10 24 6 26 4 28 0 30 3 30 M 22 22 18 24 12 24 8 28 4 34 F 24 20 20 22 10 26 4 28 5 32 M 18 22 10 26 8 30 2 30 6 35 M 16 22 8 24 4 28 0 30 7 29 F 22 20 18 24 10 28 4 30 8 50 M 24 20 20 24 16 28 10 28 9 32 M 16 24 12 26 6 28 0 30

10 35 M 10 24 8 28 4 30 0 30 11 26 F 18 24 10 26 8 26 3 28 12 25 M 16 22 12 24 6 28 0 30 13 26 M 22 20 18 24 12 26 8 28 14 32 M 20 22 14 24 8 28 4 30 15 35 M 18 22 10 26 6 28 3 30

ISOMETRIC EXERCISE

SL No AGE SEX WEEK 1 WEEK 2 WEEK 3

WEEK 4

NDI MHC NDI

MHC NDI

MHC

NDI MHC1 36 F 24 20 20 24 16 28 8 282 30 F 22 20 18 22 12 26 12 26 3 28 M 18 22 14 24 8 26 4 28 4 42 M 24 20 22 24 16 28 10 28 5 28 M 18 24 14 26 6 28 4 30 6 27 F 16 24 12 26 6 28 2 30 7 38 M 22 20 18 22 10 26 6 26 8 30 F 16 24 10 26 8 28 4 28 9 26 M 18 24 8 26 4 28 0 30 10 26 F 20 22 14 24 8 26 4 28 11 28 F 18 26 8 28 6 28 4 30 12 227 F 24 20 22 22 16 24 10 26 13 28 F 20 22 16 24 8 26 8 28 14 45 F 18 22 14 24 8 26 4 28 15 35 M 16 24 12 26 8 28 0 30